03-29-2024 SSDI LN Status: Para-aortic
Scenario:
- 5/20/2023 Cervix Biopsy-Invasive Adenocarcinoma, p16 positive.
- 6/1/2023 PET/CT-No hypermetabolic LAD in chest, abd, or pelvis. Mild hypermetabolic activity present in the cervix most likely from biopsy proven malignancy. No evidence of distant mets present.
- 6/15/2023 Exploratory laparotomy, radical abdominal hysterectomy, bilateral salpingectomy with sentinel lymph node biopsy-Invasive Adenocarcinoma, grade 2, depth of stromal invasion 6.15mm, horizontal extent of stromal invasion 14mm, silva pattern of invasion-pattern C, 0/4 pelvic lymph nodes negative, margins negative, no lymphovascular invasion, pT1b1 pN0.
- 6/30/2023 GYN note: FIGO stage 1B1 cervical cancer. No further treatment recommended.
Question: How would you code the SSDI LN Status Para-aortic?
- 0 Negative para-aortic lymph nodes
- 1 Positive para-aortic lymph nodes
- 9 Not documented in medical record/Para-aortic lymph node(s) not assessed or unknown if assessed
Answer: 0 Negative para-artic lymph nodes
Rationale: This SSDI records whether para-aortic nodes are negative or positive either clinically OR pathologically. The PET/CT stated there was no LAD present in the abdomen or pelvis. Per note 3 in the SSDI manual if there is no mention of para-aortic nodal involvement in the area being imaged you can assume they are negative. Always review the SSDI manual and notes as they provide clarification that the software drop down menu will not. If you did not see note 3 in the manual, you may have assumed this was 9 since there were no para-aortic nodes removed.
P.S. Note 3 also appears in the SSDI LN Status: Pelvic & Lymph Nodes Distant: Mediastinal, Scalene. READ THE NOTES!